11th Annual Faculty Learning Community Developers’ and Facilitators’ Summer Institute

June 23-26, 2010

Kellogg West Ranch at California Polytechnic State University
Pomona, (Southern) California

Team Registration Form

Team Name:

Team member #1

To be named later (otherwise fill out the following:)

Contact info

First Name:

Middle Name/Initial:

Last Name:

Nickname for Nametag:

Department:

Institution:

Title:

Position:

Address:

City:

State/Prov.:

ZIP/Postal Code:

Country:

Work phone #: (include country code if outside US)

Fax #: (include country code if outside US)

Cell phone #: (include country code if outside US)

Email:

Emergency contact info

Contact Name: (include country code if outside US)

Contact Phone #: (include country code if outside US)

Contact Email:

Special requirements

Sign Interpreter
Wheelchair Access

Other:

Meals:

No Beef
No Poultry
No Fish
No Pork
No Dairy Products
No Eggs

Team member #2

To be named later (otherwise fill out the following:)

Contact info

First Name:

Middle Name/Initial:

Last Name:

Nickname for Nametag:

Department:

Institution:

Title:

Position:

Address:

City:

State/Prov.:

ZIP/Postal Code:

Country:

Work phone #: (include country code if outside US)

Fax #: (include country code if outside US)

Cell phone #: (include country code if outside US)

Email:

Emergency contact info

Contact Name: (include country code if outside US)

Contact Phone #: (include country code if outside US)

Contact Email:

Special requirements

Sign Interpreter
Wheelchair Access

Other:

Meals:

No Beef
No Poultry
No Fish
No Pork
No Dairy Products
No Eggs

Team member #3

To be named later (otherwise fill out the following:)

Contact info

First Name:

Middle Name/Initial:

Last Name:

Nickname for Nametag:

Department:

Institution:

Title:

Position:

Address:

City:

State/Prov.:

ZIP/Postal Code:

Country:

Work phone #: (include country code if outside US)

Fax #: (include country code if outside US)

Cell phone #: (include country code if outside US)

Email:

Emergency contact info

Contact Name: (include country code if outside US)

Contact Phone #: (include country code if outside US)

Contact Email:

Special requirements

Sign Interpreter
Wheelchair Access

Other:

Meals:

No Beef
No Poultry
No Fish
No Pork
No Dairy Products
No Eggs

Registration Fee

Team registration: $600 per team member

Billing

Check (US funds only, please, payable to IATS)

IATS’s Federal ID Number is 25-1741294. Please mail a printout of the completed form along with your check to:

International Alliance of Teacher Scholars, Inc. (IATS)
PO Box 88-1239
Los Angeles, CA 90009

Visa
MasterCard
American Express

Credit card details

(Note: If you do not wish to submit your credit card information online, you may print a copy of this completed form, write in your credit card information, sign it, and mail it to the address above.)

Account Number:

Expiration Date:

Signature
(if mailing):
________________________________________

My billing address is the same as the one above (otherwise, complete this section)

First Name:

Last Name:

Address:

City:

State/Prov.:

ZIP/Postal Code:

Country:

Phone #: (include country code if outside US)

Other comments/requests:

STOP! Before you submit this form, please review your information, and then print a copy for your records.

International Alliance of Teacher Scholars

Twenty-Two Years of Presenting the Scholarship of Teaching and Learning

11th Annual Faculty Learning Community Developers’ and Facilitators’ Summer Institute

June 23-26, 2010

Kellogg West Ranch at California Polytechnic State University Pomona, (Southern) California

Team Registration Form

Team member #1

Meals:

Team member #2

Meals:

Team member #3

Meals:

Registration Fee

International Alliance of
Teacher Scholars

Kellogg West Ranch at California Polytechnic State University
Pomona, (Southern) California